Acute orbital myositis before Herpes zoster ophthalmicus

Corresponding author: Hyung Tae Kim, M.D., Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, P.O.Box 77, Jeonju 560-750, Korea. Tel: 82-63-230-1593, Fax: 82-63-230-8128, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC In the literature, 7% of all cases of herpes zoster present as herpes zoster ophthalmicus (HZO). Of these cases, 20 to 79% have orbital involvement [1]. Nearly all orbital tissues, including extra­ocular muscles, can be affected by the varicella zoster virus. Orbital involvement may present as keratitis, uveitis, scleritis, optic neuritis, ocular motor palsy, or postherpetic neuralgia (PHN) [2]. HZO is often suspected when ophthalmic symptoms and signs follow characteristic skin rashes and edema. Here, we report an unusual case where orbital myositis preceded vesicular skin eruptions. A 66 year­old man, who had diabetes for 15 years and hyper­ tension for 10 years, was hospitalized due to a 4­day history of left orbital shooting pain. Cranial nerve examination was nearly normal except for mild ptosis and hyperemic conjunctiva on the left side. Ophthalmic examination revealed normal intraocular pressure and normal eyeground. There were no specific findings in other physical examinations. Orbital CT revealed left orbital myositis involving superior, inferior, medial, and lateral rectus muscles compared with the right orbit (Fig. 1A). We treated him with intra­venous mannitol, 60 mg/day per­oral prednisolone (nisolone, Kukje, Seongnam, Korea), levofloxin eye­drops (Cravit, Santen, Shiga, Japan), dorzolamide HCl 2% with timolol 0.5% (Cosopt, MSD, Seoul, Korea), and latamoprost (Xalost, Taejoon, Seoul, Korea). After 3­days, he developed vesicular skin rashes at the distribution of the ophthalmic branch of the left trigeminal nerve and along the nasal ridge (Hutchinson’s sign) (Fig. 1C). He complained of severe pain in his left forehead and nose. The pattern of the pain included lancinating, shooting, and itching sensations. The pain measured by the visual analogue scale (VAS) was approximately 90/100 mm. Laboratory data, including routine biochemical and hematological exami­ nations, were normal except for glucose (423 mg/dl) and hemo­ globin A1c (10.6%). The erythrocyte sedimentation rate (ESR) was 30 mm/hr and C­reactive protein (CRP) was 0.74 mg/ dl. Immunologic studies, including IgA, IgM, C3, C4, antimi­ tochondrial antibody (AMIA), anti­nuclear antibody (ANA), and anti­double stranded DNA, were all within normal limits. Thyroid function test was normal and the VDRL/TPHA test was negative. Immediately, we treated him with 7­day intra­venous (IV) acyclovir, IV dexamethasone, and per­oral (PO) gabapentin. At the same time, we performed supraorbital and supratrochlear nerve blocks. After the nerve block, the headache and allodynia were improved. The eyelid swelling and orbital pain gradually lessened by the time he was discharged. The patient returned to our clinic with persistent left orbital pain and paroxysmal and lancinating pain along the nose ridge and forehead. We performed supraorbital and supratrochlear nerve blocks then and again in two weeks, for a total of three times. The pain was reduced to VAS 10-20/100 mm. A follow­ up orbital CT revealed resolved myositis in the rectus muscles (Fig. 1B). The patient was undergoing oral administration of gabapentin (600 mg/day). He revisited the hospital 5 months later without particular exacerbation of the pain or any other inconvenience in his daily tasks. Ophthalmic complications following HZO result directly from inflammatory changes or nerve damage, or indirectly from tissue scarring. These complications vary from mild, which may pass unnoticed, to severe, which may threaten life or sight. Except for diplopia, our patient developed characteristic symptoms of orbital myositis, such as orbital pain worsening